Acute promyelocytic leukaemia in a Nigerian patient-a case report depicting challenges in the management of haematological malignancies in Nigeria.

Introduction: Haematological malignancies (HMs) account for approximately 10% of all malignancies in sub-Saharan Africa (SSA), and their incidence is rapidly increasing. Successful management of these malignancies depends on early presentation, diagnosis and prompt initiation of treatment. However, in SSA and many low and middle-income countries, several barriers hinder the effective management of these malignancies. This case report of a patient with acute promyelocytic anaemia highlights the challenges in managing HM.

Case summary: A 31-year-old woman presented to a primary health care centre with recurrent rectal bleeding and was diagnosed with haemorrhoids. She was given iron and was reassured of her symptoms. However, when her symptoms persisted, she was referred to an academic medical centre for definitive management of her haemorrhoids. On further evaluation, she was diagnosed with acute promyelocytic anaemia based on morphologic findings, as further morphological and molecular analysis could not be done due to the non-availability of advanced diagnostic infrastructure locally. Treatment initiation with all-trans-retinoic acid (ATRA) and arsenic trioxide (ATO) was delayed due to the unavailability of the medication locally and, therefore, had to be ordered from a different country. During this time, she developed febrile neutropenia and sepsis, and her care was limited by the unavailability of blood products and the unaffordability for necessary supportive medications. Eventually, she could only start ATRA as she could not afford ATO. As a result, she could not complete the entire course of treatment. Despite this, she showed clinical improvement and some haematological recovery and was discharged but, unfortunately, was lost to follow-up in the outpatient setting.

Conclusion: Several barriers exist in managing HM and other cancers in general in SSA. Overcoming these barriers and improving outcomes in HM requires capacity building, international collaboration and political engagement.